Introduction

In May 2018, the House of Commons Standing Committee on Health released its report: ‘Pharmacare Now: Prescription Medicine Coverage for All Canadians’. This report details the current state of pharmacare in Canada and culminates in a list of 18 recommendations on how to develop a single-payer, universal pharmacare program. This means that one public plan would provide free prescription medication to Canadians.

The Current State of Pharmacare in Canada

Many Canadians currently have their prescription medication covered by a patchwork of private and public plans. Private plans are often obtained through benefits packages offered by employers while public coverage is provided through provincial programs such as the Ontario Drug Benefit (ODB) Program, which provides coverage for individuals who are over the age of 65. These private and public plans vary across Canada and are associated with high premiums, deductibles and/or co-payments that are fees that must be paid before you can receive your medication.

Then there are individuals who fall through the gaps of this patchwork. Many people who are self-employed or work part-time do not have access to private drug coverage and do not qualify for public coverage. These individuals are left with no option but to pay for medications out of pocket. Research shows that having to pay so little as two dollars for a medication can limit someone’s access to life saving drugs.[1] It is estimated that more than one in five Canadians do not take the prescription medications they require because of their high costs.[2]

Why We Need Universal Pharmacare

Having a universal pharmacare program would mean that all Canadians would have equal and efficient access to the medications they need.

Some argue that rather than moving to a single payer system we should try to fill in the gaps for those who lack coverage. Québec currently follows this model by having mandatory prescription insurance and relying on private plans to fill in the gaps. To cut costs, private companies often favour healthy individuals and charge those with pre-existing health issues high fees meaning that even if they can find coverage they likely will not be able to afford it.[3] A single payer program would eliminate the burden of having to seek out drug coverage and allow all Canadians to access medication at the time that they need it.

Access to pharmacare is a social determinant of health. When your ability to access medication is dictated by your financial situation or existing health conditions it creates major inequities across populations. This is currently the case in Canada. These inequities have a detrimental impact on peoples’ ability to work, care for the their families and contribute to society.

Doctors report that when people cannot afford their medication they either take less in an effort to make it last longer or they do not take it at all.[4] This results in an increased number of individuals ending up in the hospital or even dying as a result of health conditions that could easily be prevented or kept under control by taking their medication as prescribed by their doctor.

Hospital care is expensive and represents a significant and disproportionate part of dollars invested in health care. Our hospitals are also overcrowded. Providing individuals with needed medication will prevent unnecessary, costly hospitalization.

Not being able to afford lifesaving drugs impacts mental health as well. Many people are forced to choose between buying medications that are required for their own or a family member’s well-being and putting food on the table. This results in people not being able to function at their best and also leads to feelings of embarrassment and shame. Doctors have reported that some patients in this situation will put off going to the doctor knowing their condition is not under control because they have not been taking their medication causing issues to worsen over time.[5] Not being able to afford medication can result in anxiety and fear that over a long period of time can cause individuals to struggle with their mental health and require even more unaffordable medication to cope with the symptoms they are experiencing. And the cycle continues…

Pharmacare: Essential to a Just and Fair Society

Canadians pay some of the highest prices for prescription pharmaceuticals per capita in the world.[6] One way that countries such as New Zealand have brought down the cost of drugs is by buying from drug companies in bulk and by having a national body negotiate the price.[7] If Canada moved to a single payer universal pharmacare program, we would be positioned through our buying power, to bring down the cost of pharmaceuticals.

A common argument is that private insurance companies and the government already buy in bulk, yet medications remain costly. They ask what difference can a single payer plan make? In New Zealand, the cost of a year’s supply of Lipitor, a common cholesterol drug, is just $15 while in Canada it costs $811.[8] Clearly, the evidence indicates that we could be doing more to bring down the costs of medication.

Decreasing the number of hospital visits, working to bring down the cost of pharmaceuticals through bulk purchasing and cost negotiations and streamlining the system with a single payer program will not only improve the well-being of people but also will create significant savings which can then be put towards currently underfunded areas in our social and health systems.

Steps Forward

A report by the Parliamentary Budget Officer (PBO), “estimates total drug spending under a national Pharmacare program would amount to $20.4 billion, if implemented in 2015-2016.”[9] From 2015-2016 expenditures, “this represents savings of roughly $4.2 billion.” [10]

Besides moving to a single payer plan and buying in bulk, the House of Commons Standing Committee on Health has also recommended:

consider the establishment of a real time reporting system so doctors have more up to date information on the medications their patients are taking, and[12]

assemble a shared national ‘formulary’, which is the list of medications approved for coverage, for all provinces and territories.[13]

1. Prescribing Practices

Doctors currently receive anywhere from 9-50 hours of training in clinical pharmacology in medical school.[14] There are over 13,000 drugs on the market in Canada. As our population ages, a growing number of seniors suffering from chronic health conditions, take 10 or more medications at once.[15] Doctors do not receive the appropriate training to navigate this complex situation.[16]

A common fear amongst those who are against universal pharmacare is that if there is easy access to drugs people will over use medication. Part of ensuring this does not happen would be to improve doctor training in clinical pharmacology.[17] Dr. Cindy Forbes also recommends that having real time access to a record of the medications a patient is taking would contribute to better and more informed prescribing practices.[18]

2. Inefficiencies

There is room to improve the relationship between physicians and pharmacists.[19] Throughout their four years of professional school, pharmacists receive extensive training in clinical pharmacology and toxicology providing them with valuable knowledge of all drugs on the market and their interactions in the body. Improving the relationship between physicians and pharmacists creates more opportunity for collaboration. Pharmacists could work together with doctors to assemble care plans for patients with complex medication needs.

Pharmacists are also easily accessible to the community and can provide valuable and immediate information on prescription or over the counter medications, which can help to equalize some of the burden that usually falls on doctors as a result of the general public not fully understanding the role of a pharmacist.

Currently, pharmacists in Ontario can do Medschecks, which are one on one meetings with a patient to discuss all medications they are currently taking. The results of this meeting are then sent to the doctor to keep them updated. In theory this system makes sense, however there are many extenuating circumstances that prevent Medschecks from occurring as efficiently as they are intended.

According the Ontario Pharmacist’s Association, a Medscheck should take around 20-30 minutes.[20] However, many pharmacists work alone without the help of an assistant, something that is dictated by the head office of the large corporations that house community pharmacies, meaning they often do not have the required time to spend doing multiple Medschecks per day. Possible improvements to this system maybe a designated pharmacist working on Medschecks while another pharmacist tends to the flow of patients. Medscheck opens lines of communication between pharmacists and physicians to allow for valuable up-to-date medical information to be shared with all members of a patient’s circle of care.[21]

3. Inequities

The formulary[22] currently varies for each of the provinces and territories. This creates inequities amongst Canadians as someone living in Alberta may be able to access medication which is not covered in Ontario. We also need to assess what drugs are currently on the formulary. A common myth is that newer medications are better medications. In reality newer medications are often very similar to medications already on the market but cost more. Also, new medications can cause unknown side effects. When a medication has been on the market for a number of years, we know what the long-term effects are.

In the Standing Committee’s report, Dr. Cara Tannenbaum reminds us of the gender impact in pharmaceuticals. In establishing a shared formulary, we need to be conscious of the fact that women often require different medications or different dosages than men, which can impact the cost of medications. In establishing a shared national formulary, a sufficient number of hormone related contraceptives need to be included.[23]

Who is left out?

Although universal pharmacare is the logical next step in improving Canada’s health care system, it is important to acknowledge that some will continue to experience barriers to accessing medications. If the pharmacare program follows the current system modeled in hospitals, individuals will require a health card to access services. Individuals living in Canada who may be undocumented or who are unable to obtain a health card for extenuating reasons such as homelessness, mental health or mobility issues will continue to face barriers in accessing their medications.

Implications for Private Insurance Providers

If Canada moves to a single-payer, universal pharmacare program, drug coverage from private insurance companies will likely be eliminated. The Standing Committee’s report indicates we need a better understanding of how this will impact job loss in industry and whether these jobs can be transferred to whatever entity would manage such a program.[24]

Conclusion

From both an ethical and a financial standpoint, universal pharmacare is an important pillar of Canada’s and Ontario’s safety net. Universal pharmacare must be a joint policy and program initiative between the federal and the provincial/territorial governments.

As the cost of pharmaceuticals continues to rise the limitations of our current system, both its inefficiency and unsustainability, become clear. Implementing universal pharmacare will create a more effective, equitable system with fewer barriers to access life saving medications. This improves the health and well-being of Canadians.